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2. Name of Complainant (last, first, middle)*
4. Name of Person Filing Report (if different from above)
6. Sex
   -- Select One --MaleFemale
7. Race
8. Date of Birth
10. Full Address
12. Work Phone
13. Home Phone
14. Email
16. Involved Employee(s) (if known)
17. SPD Case Number (if known)
19. Location of Incident
21. Date & Time of Incident
    Date & Time of Incident Start Date

    Date & Time of Incident Start Time

    —

    Date & Time of Incident End Date

    Date & Time of Incident End Time
23. Witness Name, Address, Phone
25. Witness Name, Address, Phone
27. Describe What Happened
29. How would you like to see this complaint resolved?
31. By typing my name in the space below, I hereby certify that the statements given by me herein are true and accurate to the best of my personal knowledge. I understand that making intentional false declarations to public servants or untrue statements under oath or affirmation may be punishable by law.
33. Name of Complainant*
34. Date*
    Date

    Date
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field